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1 A Longitudinal Study of Caregivers’ Perception of Long-Term-Care Services and Services Use in Singapore Chang Liu Assistant Professor Program in Health.

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Presentation on theme: "1 A Longitudinal Study of Caregivers’ Perception of Long-Term-Care Services and Services Use in Singapore Chang Liu Assistant Professor Program in Health."— Presentation transcript:

1 1 A Longitudinal Study of Caregivers’ Perception of Long-Term-Care Services and Services Use in Singapore Chang Liu Assistant Professor Program in Health Services & Systems Research Email: chang.liu@duke-nus.edu.sgchang.liu@duke-nus.edu.sg April 17, 2014

2 Demographic Challenges Lower fertility Increased longevity Later marriage Higher rate of non-marriage and divorce Source: World Population Prospects: The 2010 Revision, http://esa.un.org/unpd/wpp/index.htm 2

3 Demographic Challenges The number and proportion of highly disabled elderlies are rising. Source: Ansah JP, Matchar DB, Love SR, et al. 2013. 1-2 ADL limitations 3

4 Demographic Challenges The number and proportion of highly disabled elderlies are rising. Family are getting smaller 1-2 ADL limitations Source: Ansah JP, Matchar DB, Love SR, et al. 2013. 4

5 Demographic Challenges The number and proportion of highly disabled elderlies are rising. Family are getting smaller More caregivers will have significant depression attributable to caregiving Source: Malhotra C, Malhotra R, Østbye T,,et al. 2012. 1-2 ADL limitations Individuals with depression attributable to caregiving Individuals with depression irrespective of caregiving 5

6 Source: Straits Times. Temporary beds in air-conditioned tent @ Changi General How much can the system handle? 6

7 Polyclinic Specialty Outpatient Clinic Acute Hospital Community services General Practitioner Service integration Transitional care Community services General Practitioner Polyclinic Specialty Outpatient Clinic Acute Hospital Enhanced Community services Self-care Family Medical Clinic A framework for addressing the challenges Agency for Integrated Care (AIC) 7

8 Long-Term Care Services Use Governmental investments on formal Long-term Care Services (LTCS) – Provide higher subsidy in 2012 – Invest S$ 500 million on eldercare facilities from 2013-16 – Add 3000+ NH beds by 2016 1 – Planned to increase NH beds by 70% by 2020 – from 9,000 today to 15,600 1 LTCS utilization is low compared to Western societies 2 – AIC: take-up rate for some community services is less than 50% Should we promote take-up LTCS given that: – Limited information and awareness of the services – LTCS can be cost-effective for the society 3 8 Source: 1. William Haseltine, Affordable Excellence: the Singapore Healthcare Story, 2013. 2. Koh GC-H, et al, 2012; Wee, Liu et al. 2014. 3. Khiaocharoen et al, 2012; Saka et al, 2009; Yuan et al, 2014

9 What are the factors associated with the take-up of formal LTCS? And whether they differ across different LTCS? Are there some sub-groups of population with extremely low utilization rates (outliners)? What are the potential ways to improve take-up of LTCS? Can we increase the take-up rate by impacting the caregiver’s perception on services? 9 Main Research Questions

10 Previous Studies The Andersen Model of Health Care Utilization 1 Does not consider caregiver (CG) characteristics, which are important in the Asian context. – Care recipients (CR) for LTCS have higher dependent level – CG and CR are more likely to live together – Social norm Does not account for their awareness and perception about the services 2 With limited empirical studies in Asia: Hong Kong (2009), Japan (2011) 3 Source : 1. RM Andersen. J Health Social Behavior 1995; 36:1-10. 2. Ching AT et al, 2010; Gneezy U, et al, 2011; Crawford GS, et al, 2005. 3. Lou et al, 2011; Murayama et al, 2011. 10

11 AIC LTC Referral Study: Survey and Data A Longitudinal study – Dyads of care recipients and their caregivers – Three waves over a 12 month period Gathered information on both CR and CG: demographic, health status, financial resources, living arrangement, knowledge and awareness, etc. Two measures of LTCS utilization: 1)whether took-up the referral 2)current LTC services use (a choice of nursing home, center-based services, home-based services, family and friends, maid). CG’s perception/rating of formal and informal LTCS: quality, convenience, social connectedness, and affordability (score range from 1-5). 11

12 Stratified sampling by: 1)Service types - Day Rehabilitation, Dementia Day Care, Home Medical, Home Nursing, Home Therapy, and Nursing Home 2)Socio-economic characteristics – Seven Mosaic Singapore groups* Response rate : 43% First wave analytic sample: 1586 dyads 553 care recipients, 1027 proxies and 1502 caregivers Note: Mosaic Singapore is a geo-demographic consumer segmentation system, developed based on more than 20 years of segmentation development expertise. It classifies all Singapore households and neighborhoods into 7 groupings that share similar demographic and socio- economic characteristics. It paints a rich picture of Singapore consumers in terms of their socio-demographics, lifestyles, culture and behaviors. 12 AIC LTC Referral Study: Survey and Data

13 CR Baseline Characteristics 13 Variable (%) Any Community LTC Services (n=1,416) Center-Based LTC Services (n=792) Home-Based LTC Services (n=624) P-Value Age: <=64 22.423.221.3 0.096 65-74 24.926.522.8 >=75 52.850.355.9 Female 55.9 0.999 Married 50.553.347.0 0.020 Education: None 41.737.247.3 0.001 Primary 30.131.728.0 Secondary+ 28.331.124.7 Household Income: <500 38.835.043.8 0.000 500-1999 27.431.622.1 2000+ 15.115.714.4 Don’t know/refuse 18.617.819.7 Comorbidity: 0-1 18.817.720.2 0.000 2-4 50.152.247.6 5+ 31.130.232.2 ADL Score: Low 38.148.724.5 0.000 Medium 31.837.524.5 High 30.213.851.0

14 Take-up of Referred LTC Services 14

15 Dependent variables: 1)whether took-up the referral 2)current LTC services use (a choice of nursing home, center-based services, home-based services, family and friends, maid). Independent variables: CG’s perception score on quality, convenience, social connectedness, and affordability (score range from 1-5). Covariates: CR’s age, sex, housing, education, comorbidity, ADL, iADL, income, Medisave status, and CG’s age, sex, housing, health, # of family members in the household, decision, and whether or not they have a maid. Statistical methods: 1)Logistic Regression 2)Conditional Logistic Regression Two waves data : repeated cross-sectional and longitudinal analysis 15 Approaches

16 Odds Ratio of Referred LTC Service Utilization [95% CI] Any LTC ServicesCenter-Based ServicesHome-Based Services Wave 1 + Wave 2N=1,795N=875N=650 Quality Score 1.27** [1.08, 1.48] 1.34* [1.06, 1.70] 1.18 [0.89, 1.15] Convenience Score 1.24** [1.09, 1.41] 1.31* [1.08, 1.60] 1.22 [0.96, 1.54] Social Connectedness Score 1.07 [0.94, 1.21] 1.21 [0.99, 1.48] 0.92 [0.75, 1.13] Affordability Score 1.34*** [1.20, 1.49] 1.40*** [1.18, 1.66] 1.42*** [1.19, 1.69] Adjusted for care recipients’ age, sex, housing, education, comorbidity, ADL, iADL, income, Medisave status, and care givers’ age, sex, housing, health, # of family members in the household, decision, and whether or not they have a maid. *p<.05 **p<0.01 ***p<0.001 Perception Scores and Take-up Referred LTCS 16

17 Odds Ratio of Referred LTC Service Utilization [95% CI] Any LTC ServicesCenter-Based ServicesHome-Based Services Wave 1 on Wave 2N=782N=406N=264 Quality Score 1.19 [0.94, 1.51] 1.12 [0.77, 1.63] 1.32 [0.81, 2.15] Convenience Score 0.98 [0.80, 1.20] 1.25 [0.91, 1.73] 0.70 [0.44, 1.10] Social Connectedness Score 1.11 [0.90, 1.37] 1.22 [0.89, 1.67] 1.50 [0.97, 2.32] Affordability Score 1.21* [1.03, 1.42] 1.34* [1.04, 1.74] 1.05 [0.77, 1.42] Adjusted for care recipients’ age, sex, housing, education, comorbidity, ADL, iADL, income, Medisave status, and care givers’ age, sex, housing, health, # of family members in the household, decision, and whether or not they have a maid. *p<.05 **p<0.01 ***p<0.001 Perception Scores and Take-up Referred LTCS 17

18 Perception Scores and Current Service Utilization 18 Odds Ratio of Current LTC Service Utilization [95% CI] Model 1Model 2 Wave 1 + Wave 2N=5,996N=3,180 Quality Score 1.18* [1.03, 1.34] 1.14 [0.93, 1.39] Convenience Score 1.17* [1.04, 1.32] 1.19 [0.99, 1.43] Social Connectedness Score 1.07 [0.96, 1.20] 0.96 [0.82, 1.13] Affordability Score 1.29*** [1.18, 1.42] 1.39*** [1.21, 1.61] In these conditional logistic models, each patient becomes 5 observations, each stands for one type of current LTC services: community-based, home-based, nursing home, family and friends, and maid. In model 1 we only adjusted for whether referred service type; in model 2, we, in addition, adjusted for care recipients’ ADL and iADL. *p<.05 **p<0.01 ***p<0.001

19 Top Reasons for Withdrawal/Rejection of Referred Service 19

20 Household Income and Affordability 20

21 Next Steps Examine effect of use/non-use on subsequent health status, other service use and quality of life System modeling the demand of formal LTCS for lower income, moderate to high ADL population Design a randomized controlled trial (RCT) to improve the uptake of and adherence to outpatient rehabilitation service among stroke patients 21

22 Collaborators Agency for Integrated Care (AIC) Wee Shiou Liang Wayne Chong Changi Hospital Goh Soon Noi Duke-NUS Kirsten Eom Angelique Chan Amudha Aravindhan Tian Yuan David Matchar 22

23 Thank You! 23 “Health economics (health services and systems research) can be intellectually stimulating, socially useful, and personally rewarding.” - Victor R. Fuchs

24 24 A Longitudinal Study of Caregivers’ Perception of Long-Term-Care Services and Services Use in Singapore Chang Liu Assistant Professor Program in Health Services & Systems Research Email: chang.liu@duke-nus.edu.sgchang.liu@duke-nus.edu.sg April 17, 2014

25 Referred vs. Current Services 25


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